总额付费下医保费用考核指标精细化管理探究

Research of Hospital Medical Insurance Costs Index Fine Management under the Total Budget Payment System

目的:针对医院传统医疗费用管理的局限性,探究总额付费下医疗费用考核的动态评价指标与管理策略。方法:结合德尔菲法、比较法等,对医院医疗业务大数据进行挖掘分析,构建一套科学、合理的医疗费用管控平台,以分析比较各科室、病区职工医保及居民医保的医疗费用水平及费用明细的结构占比,评估其合理性。结果:依托此医疗费用管理系统,医院医保办将市社保中心下达的年度总额进行合理分配,制定科学的人均定额指标,医疗资源得以高效利用;从多维度出发控制医疗费用上涨;医务人员在诊疗行为方面趋于规范化,不合理用药现象减少。结论:总额付费下医保费用考核指标的有效管控,可充分发挥医疗保险对医疗服务行为和费用的调控引导与监督制约作用,构筑了和谐的医、保、患关系。

Objective：Aiming at the limitation of hospital traditional medical expenses management,to explore the dynamic evaluation index and management strategy of medical expenses examination under total payment. Methods：Depth analysis of hospital medical business data by means of Delphi and comparative research methods. Build a scientific and reasonable medical expenses control platform,in order to analyze and compare the medical expenses and cost structure proportion of every department and ward,and assess the reasonableness of it. Results：Relying on medical expenses management system,the Medicare Office allocates the annual total to each ward and sets up a scientific per capita quota,in order to make efficient use of medical resources. Make use of multi-angle methods to control rising health care costs;Medical staffs’treatment behavior tends to standardization and the phenomenon of irrational drug use has been reduced. Conclusion：Effective control of medical insurance expenses under global budge,can give full play to medical insurance on the behavior and cost of medical services guidance and supervision.